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SIGNIFICANCE: Think Tank 2019 affirmed that the rate of infection associated with contact lenses has not changed in several decades. Also, there is a trend toward more serious infections associated with Acanthamoeba and fungi. The growing use of contact lenses in children demands our attention with surveillance and case-control studies. PURPOSE: The American Academy of Optometry (AAO) gathered researchers and key opinion leaders from around the world to discuss contact lens-associated microbial keratitis at the 2019 AAO Annual Meeting. METHODS: Experts presented within four sessions. Session 1 covered the epidemiology of microbial keratitis, pathogenesis of Pseudomonas aeruginosa, and the role of lens care systems and storage cases in corneal disease. Session 2 covered nonbacterial forms of keratitis in contact lens wearers. Session 3 covered future needs, challenges, and research questions in relation to microbial keratitis in youth and myopia control, microbiome, antimicrobial surfaces, and genetic susceptibility. Session 4 covered compliance and communication imperatives. RESULTS: The absolute rate of microbial keratitis has remained very consistent for three decades despite new technologies, and extended wear significantly increases the risk. Improved oxygen delivery afforded by silicone hydrogel lenses has not impacted the rates, and although the introduction of daily disposable lenses has minimized the risk of severe disease, there is no consistent evidence that they have altered the overall rate of microbial keratitis. Overnight orthokeratology lenses may increase the risk of microbial keratitis, especially secondary to Acanthamoeba, in children. Compliance remains a concern and a significant risk factor for disease. New insights into host microbiome and genetic susceptibility may uncover new theories. More studies such as case-control designs suited for rare diseases and registries are needed. CONCLUSIONS: The first annual AAO Think Tank acknowledged that the risk of microbial keratitis has not decreased over decades, despite innovation. Important questions and research directions remain.
Assuntos
Ceratite por Acanthamoeba/epidemiologia , Lentes de Contato/efeitos adversos , Infecções Oculares Bacterianas/epidemiologia , Infecções Oculares Fúngicas/epidemiologia , Infecções Oculares Parasitárias/epidemiologia , Ceratite/epidemiologia , Optometria/organização & administração , Academias e Institutos , Ceratite por Acanthamoeba/parasitologia , Estudos Epidemiológicos , Infecções Oculares Bacterianas/microbiologia , Infecções Oculares Fúngicas/microbiologia , Infecções Oculares Parasitárias/parasitologia , Humanos , Incidência , Ceratite/microbiologia , Fatores de Risco , Estados Unidos/epidemiologiaRESUMO
OBJECTIVES: Myopia progression is a significant public health issue. Methods to halt myopia progression in minors continue to gain momentum. Orthokeratology, with market penetrance estimates approximating 1%, is a corneal reshaping therapy and potential myopia progression treatment. Our objective was to explore whether orthokeratology may increase the frequency of Acanthamoeba keratitis compared with other lens modalities. METHODS: Individuals less than 18 years diagnosed with Acanthamoeba keratitis (AK) at the University of Illinois at Chicago (UIC) Cornea Service between January 1st, 2003, and December 31st, 2016, were retrospectively reviewed. Subjects were grouped by lens modality (soft, rigid gas permeable [RGP], and orthokeratology), and all cases with orthokeratology lens use were reviewed. The primary outcome was a history of orthokeratology lens use in minors diagnosed with AK. RESULTS: Forty-seven contact lens users less than 18 years were diagnosed with AK. The mean age was 15.0 years (range 12-17), 26 (55%) were women, and 4 (8.5%) had bilateral disease. Lens modality included 6 (13%) with orthokeratology, 39 (83%) with soft contact lenses, 0 with nonorthokeratology RGP (0%), and 2 (4%) unknown. CONCLUSIONS: The proportion of orthokeratology cases among AK minors (13%) in our case series exceeds the expected proportion of orthokeratology cases expected based on orthokeratology market penetrance (1%). Results from this case series suggest a potential increased risk of AK in orthokeratology users compared with other lens modalities. In the context of the current myopia epidemic and concerns for halting myopia progression in minors, caution should be exercised when selecting appropriate treatment options to minimize the risk of AK.
Assuntos
Ceratite por Acanthamoeba , Lentes de Contato Hidrofílicas , Miopia , Ceratite por Acanthamoeba/epidemiologia , Ceratite por Acanthamoeba/etiologia , Adolescente , Criança , Lentes de Contato Hidrofílicas/efeitos adversos , Córnea , Feminino , Humanos , Menores de Idade , Miopia/terapia , Estudos RetrospectivosRESUMO
PURPOSE: To associate donor, recipient, and operative factors with graft success 3 years after Descemet stripping automated endothelial keratoplasty (DSAEK) in the Cornea Preservation Time Study (CPTS). DESIGN: Cohort study within a multicenter, double-masked, randomized clinical trial. PARTICIPANTS: One thousand ninety individuals (1330 study eyes) with a median age of 70 years undergoing DSAEK for Fuchs endothelial corneal dystrophy (94% of eyes) or pseudophakic or aphakic corneal edema (PACE; 6% of eyes). METHODS: Eyes undergoing DSAEK were randomized to receive a donor cornea with preservation time (PT) of 0 to 7 days (n = 675) or 8 to 14 days (n = 655). Donor, recipient, and operative parameters were recorded prospectively. Graft failure was defined as regraft for any reason, a graft that failed to clear by 8 weeks after surgery, or an initially clear graft that became and remained cloudy for 90 days. Failure in the first 8 weeks was classified further as primary donor failure or early failure, in the absence or presence of operative complications, respectively. Proportional hazards and logistic regression models were used to estimate risk ratios (RR) and 99% confidence intervals (CIs) for graft failure. MAIN OUTCOME MEASURES: Graft success at 3 years. RESULTS: One thousand two hundred fifty-one of 1330 grafts (94%) remained clear at 3 years and were considered successful. After adjusting for PT, tissue from donors with diabetes (RR, 2.35; 99% CI, 1.03-5.33) and operative complications (RR, 4.21; 99% CI, 1.42-12.47) were associated with increased risk for primary or early failure. Preoperative diagnosis of PACE (RR, 3.59; 99% CI, 1.05-12.24) was associated with increased risk for late failure by 3 years after surgery compared with Fuchs dystrophy. Graft success showed little variation among other factors evaluated, including donor age (RR, 1.19 per decade; 99% CI, 0.91-1.56 per decade), preoperative donor endothelial cell density (RR, 1.10 per 500 cells; 99% CI, 0.74-1.63 per 500 cells), graft diameter (RR, 1.22 per 1 mm; 99% CI, 0.39-3.76 per 1 mm), and injector use for graft insertion (RR, 0.92; 99% CI, 0.40-2.10). CONCLUSIONS: Descemet stripping automated endothelial keratoplasty success in the early and entire postoperative period is more likely when the donor did not have diabetes and was without operative complications and in the long-term postoperative period in recipients with Fuchs dystrophy compared with those with PACE. Mechanisms whereby diabetic donors and PACE recipients reduce the rate of graft success after DSAEK warrant further study.
Assuntos
Edema da Córnea/cirurgia , Ceratoplastia Endotelial com Remoção da Lâmina Limitante Posterior/métodos , Distrofia Endotelial de Fuchs/cirurgia , Sobrevivência de Enxerto/fisiologia , Preservação de Órgãos , Doadores de Tecidos , Transplantados , Adulto , Idoso , Contagem de Células , Estudos de Coortes , Edema da Córnea/fisiopatologia , Método Duplo-Cego , Endotélio Corneano/citologia , Bancos de Olhos , Feminino , Distrofia Endotelial de Fuchs/fisiopatologia , Humanos , Masculino , Pessoa de Meia-Idade , Período Pós-Operatório , Fatores de Tempo , Estudos de Tempo e Movimento , Acuidade Visual/fisiologiaRESUMO
OBJECTIVES: To determine the rate of biofilm formation on bandage contact lenses worn by patients with the Boston type 1 keratoprosthesis (K-Pro) while on prophylactic topical vancomycin versus linezolid. METHODS: Patients wearing a bandage contact lens (BCL) with a K-Pro were eligible for enrollment. After irrigation of the ocular surface with 5% povidone-iodine solution, each patient was placed on either topical vancomycin 15 mg/mL or linezolid 0.2% BID for one month. At the one-month visit, the BCL was collected and stored in fixative solution. Standard photographs were taken of each lens at high magnification using scanning electron microscopy (SEM), which were subsequently analyzed for evidence of biofilm. RESULTS: Nineteen contact lenses were obtained from 12 K-Pro patients at the Illinois Eye and Ear Infirmary. Zero of eight (0%; 95% CI=0 to 37%) contact lenses from patients treated with topical vancomycin, and 1 of 11 (9%; 95% CI=0 to 41%; P-value=1.00) contact lenses from patients treated with topical linezolid were found to have biofilm formation at one month as detected by SEM. None of the patients developed a clinically significant infection while on either prophylactic vancomycin or linezolid during the study period. CONCLUSIONS: Overall, the rate of biofilm formation as detected by SEM on the surface of bandage contact lenses was low. These results suggest that vancomycin and linezolid are both relatively effective in reducing biofilm-forming bacterial growth at one month. Accordingly, linezolid may be an effective alternative to vancomycin in patients with allergy or intolerance. However, further investigation is required to develop evidence-based antibiotic prophylaxis regimens.
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Antibacterianos/uso terapêutico , Antibioticoprofilaxia , Biofilmes , Lentes de Contato Hidrofílicas/microbiologia , Doenças da Córnea/prevenção & controle , Linezolida/uso terapêutico , Próteses e Implantes/efeitos adversos , Infecções Relacionadas à Prótese , Vancomicina/uso terapêutico , Antibacterianos/administração & dosagem , Bandagens , Biofilmes/efeitos dos fármacos , Biofilmes/crescimento & desenvolvimento , Humanos , Linezolida/administração & dosagem , Projetos Piloto , Infecções Relacionadas à Prótese/microbiologia , Infecções Relacionadas à Prótese/prevenção & controle , Vancomicina/administração & dosagemRESUMO
A 42-year-old man with ocular erythema and scarring had a conjunctival biopsy revealing depostion of IgM and C3 without IgG at the epithelial basement membrane zone. Treatment with doxycyline, dapsone, and mycophenolate mofetil was unsuccessful and treatment with rituximab has led to partial remission of the conjunctival inflammation. He has undergone 4 cycles of rituximab treatment at intervals of 12 to 18 months.
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Anticorpos Anti-Idiotípicos/imunologia , Autoanticorpos/imunologia , Túnica Conjuntiva/patologia , Imunidade Inata , Imunoglobulina M/imunologia , Penfigoide Mucomembranoso Benigno/imunologia , Adulto , Biópsia , Técnica Direta de Fluorescência para Anticorpo/métodos , Seguimentos , Humanos , Fatores Imunológicos/uso terapêutico , Masculino , Penfigoide Mucomembranoso Benigno/diagnóstico , Penfigoide Mucomembranoso Benigno/tratamento farmacológico , Indução de Remissão , Rituximab/uso terapêuticoAssuntos
Infecções Bacterianas/complicações , Úlcera da Córnea/etiologia , Saúde Global , Doenças Negligenciadas/epidemiologia , Antibacterianos/uso terapêutico , Úlcera da Córnea/tratamento farmacológico , Úlcera da Córnea/prevenção & controle , Países em Desenvolvimento , Promoção da Saúde/organização & administração , Humanos , Hanseníase/complicações , Oncocercose Ocular/complicações , Tracoma/complicaçõesRESUMO
PURPOSE: To develop an artificial intelligence (AI) model to diagnose Acanthamoeba keratitis (AK) based on in vivo confocal microscopy (IVCM) images extracted from the Heidelberg Retinal Tomograph 3 (HRT 3). METHODS: This retrospective cohort study utilized HRT 3 IVCM images from patients who had received a culture-confirmed diagnosis of AK between 2013 and 2021 at Massachusetts Eye and Ear. Two cornea specialists independently labeled the images as AK or nonspecific finding (NSF) in a blind manner. Deep learning tasks were then conducted through Python and TensorFlow. Distinguishing between AK and NSF was designed as the task and completed through a devised convolutional neural network. RESULTS: A dataset of 3312 confocal images from 17 patients with a culture-confirmed diagnosis of AK was used in this study. The inter-rater agreement for identifying the presence or absence of AK in IVCM images was 84 %, corresponding to a total of 2782 images on which both observers agreed and which were included in the model. 1242 and 1265 images of AK and NSF, respectively, were utilized in the training and validation sets, and 173 and 102 images of AK and NSF, respectively, were utilized in the evaluation set. Our model had an accuracy, sensitivity, and specificity of 76 % each, and a precision of 78 %. CONCLUSIONS: We developed an HRT-based IVCM AI model for AK diagnosis utilizing culture-confirmed cases of AK. We achieved good accuracy in diagnosing AK and our model holds significant promise in the clinical application of AI in improving early AK diagnosis.
RESUMO
PURPOSE: The aim of this study was to evaluate characteristics and outcomes of pediatric phlyctenulosis at a tertiary care center in the United States. METHODS: A retrospective cohort study of phlyctenulosis diagnosis in patients younger than 18 years was conducted. Demographics, presenting features, treatment regimens, and outcomes were analyzed. RESULTS: Seventy patients (95 eyes) with phlyctenulosis were identified. Fifty-four patients (77.1%) were Hispanic, which was greater than the center's proportion of pediatric patients identifying as Hispanic (53.8%, P < 0.0001). Common comorbidities included adjacent external/lid disease (82.9%), allergic/atopic disease (18.6%), and viral infections (8.6%). Nine patients had tuberculosis testing which was negative in all cases. Five patients had vitamin A testing which revealed deficiency in 1 patient. Treatment regimens were diverse and included varying combinations of topical and systemic medications. Complications included corneal scarring (27.4%), corneal neovascularization (40.0%), amblyopia (16.8%), corneal perforation (3.2%), and severe limbal stem-cell deficiency (1.1%). 26.3% of affected eyes had final visual acuity worse than 20/40. Differences in rates of corneal complications between Hispanic and non-Hispanic patients were not statistically significant, although severe corneal complications including perforation occurred only in the Hispanic group. CONCLUSIONS: This study presents a modern cohort of phlyctenulosis at a tertiary center in the United States and includes a larger proportion of Hispanic patients than expected. Phlyctenulosis carries high corneal morbidity and may frequently result in reduced visual acuity. Similar rates of corneal complications were seen in Hispanic versus non-Hispanic patients, but severe corneal complications were seen only in the Hispanic group.
Assuntos
Doenças da Córnea , Ceratite , Ceratoconjuntivite , Humanos , Criança , Estados Unidos/epidemiologia , Estudos Retrospectivos , Centros de Atenção Terciária , Córnea , Ceratite/complicações , Ceratoconjuntivite/tratamento farmacológico , Doenças da Córnea/diagnósticoRESUMO
Acanthamoeba keratitis (AK) is a severe cause of infectious keratitis and represents a significant clinical challenge. Recent literature regarding AK epidemiology, diagnosis, treatment modalities, and prognosis is reviewed and synthesized to propose an algorithmic protocol for AK management. Globally, AK outbreaks in developed countries are ongoing, and AK rates have increased. Moreover, current outbreaks may carry a worse prognosis than prior outbreaks. Despite identification of contact lens solutions implicated in AK outbreaks and the consequent market recall of these products, outbreaks persist. Acanthamoeba keratitis afflicts not only refractive soft contact lens users but also cosmetic contact lens users and gas permeable (especially orthokeratology) lens users. Innovations in in vivo confocal microscopy and PCR assays have increased the role for these adjuvant tests alongside corneal smear and culture in a multimodal diagnostic approach to suspected AK. Biguanides (such as chlorhexidine and polyhexamethylene biguanide) and diamidines (propamidine isethionate and hexamidine) remain cornerstones of AK management, and evidence for other treatment modalities continues to evolve. Voriconazole in topical and systemic forms may be useful as adjuvant therapy. The anti-leishmaniasis drug miltefosine, recently given orphan drug status by the United States Food and Drug Administration, has increasing evidence supporting a role in patients with severe/refractory disease. Prior topical corticosteroids have been consistently shown to be associated with worse outcomes in AK. Although not historically thought of as a treatment modality, benzalkonium chloride preservative may be leveraged for its anti-Acanthamoebal properties. The role of Rose-Bengal photodynamic antimicrobial therapy is evolving in selected cases of AK.
Assuntos
Ceratite por Acanthamoeba , Lentes de Contato , Fotoquimioterapia , Ceratite por Acanthamoeba/diagnóstico , Ceratite por Acanthamoeba/tratamento farmacológico , Ceratite por Acanthamoeba/epidemiologia , Lentes de Contato/efeitos adversos , Córnea , Humanos , PrognósticoRESUMO
OBJECTIVES: Central toxic keratopathy (CTK) after refractive surgery is a syndrome characterized by central corneal opacification, thinning, and a hyperopic shift. We report a similar presentation after extended contact lens wear. No prior confocal imaging has been reported in this contact lens case syndrome. METHODS: A 45-year-old white man presented with 3 weeks of photophobia and foreign body sensation after extended contact lens wear. Initial examination showed central stromal opacities, thinning, and hyperopic shifts, more in the right eye than in the left eye. RESULTS: Initial confocal microscopy showed collagen fibril edema and rearrangement with cellular infiltration and sparse refractile elements similar in appearance to immunoglobulin. The patient was treated with topical corticosteroids and was told to discontinue contact lenses. At 7 months, there was trace corneal haze, resolved corneal thinning, a 2-D residual hyperopic shift in the right eye, and a 1.5-D shift in the left eye. CONCLUSIONS: The clinical findings in our patient having contact lens keratitis resemble those of CTK postrefractive surgery cases, suggesting a similar mechanism. The lack of necrotic debris supports a cytokine-triggered apoptosis over an inflammatory cell-mediated necrosis as the cause of stromal tissue loss. Future confocal microscopy at different stages will help clarify the pathophysiologic condition of this rare syndrome.
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Lentes de Contato de Uso Prolongado/efeitos adversos , Ceratite/etiologia , Microscopia Confocal , Diagnóstico Diferencial , Humanos , Ceratite/diagnóstico , Masculino , Pessoa de Meia-IdadeRESUMO
PURPOSE: To survey pediatric ophthalmologists on their perspectives of artificial intelligence (AI) in ophthalmology. METHODS: This is a subgroup analysis of a study previously reported. In March 2019, members of the American Association for Pediatric Ophthalmology and Strabismus (AAPOS) were recruited via the online AAPOS discussion board to voluntarily complete a Web-based survey consisting of 15 items. Survey items assessed the extent participants "agreed" or "disagreed" with statements on the perceived benefits and concerns of AI in ophthalmology. Responses were analyzed using descriptive statistics. RESULTS: A total of 80 pediatric ophthalmologists who are members of AAPOS completed the survey. The mean number of years since graduating residency was 21 years (range, 0-46). Overall, 91% (73/80) reported understanding the concept of AI, 70% (56/80) believed AI will improve the practice of ophthalmology, 68% (54/80) reported willingness to incorporate AI into their clinical practice, 65% (52/80) did not believe AI will replace physicians, and 71% (57/80) believed AI should be incorporated into medical school and residency curricula. However, 15% (12/80) were concerned that AI will replace physicians, 26% (21/80) believed AI will harm the patient-physician relationship, and 46% (37/80) reported concern over the diagnostic accuracy of AI. CONCLUSIONS: Most pediatric ophthalmologists in this survey viewed the role of AI in ophthalmology positively.
Assuntos
Internato e Residência , Oftalmologistas , Oftalmologia , Estrabismo , Inteligência Artificial , Criança , Humanos , Oftalmologia/educação , Inquéritos e Questionários , Estados UnidosRESUMO
Purpose: To report a series of cases demonstrating the resolution of Acanthamoeba keratitis (AK) with adjunctive use of oral miltefosine.Methods: Retrospective case series.Results: The first case was a 27-year-old female who presented with severe pain and photophobia. The diagnosis of AK was made with confocal microscopy, which revealed a significant burden of stromal cysts. After approximately 2 weeks of adjunctive oral miltefosine therapy, there was a severe inflammatory response within the cornea followed by quick resolution of the AK. The second case was a 31-year-old male in whom the diagnosis of AK was confirmed by culture and polymerase chain reaction. Adjunctive oral miltefosine was started 3 months after presentation, leading to a quick resolution.Conclusions: Oral miltefosine may have cysticidal properties and should be considered as adjunctive therapy for the treatment of AK, particularly in cases with a significant burden of cysts or in cases recalcitrant to other treatments.
Assuntos
Ceratite por Acanthamoeba/tratamento farmacológico , Córnea/patologia , Infecções Oculares Parasitárias/tratamento farmacológico , Fosforilcolina/análogos & derivados , Acuidade Visual , Acanthamoeba/genética , Ceratite por Acanthamoeba/diagnóstico , Ceratite por Acanthamoeba/parasitologia , Administração Oral , Adulto , Antiprotozoários/administração & dosagem , Córnea/parasitologia , DNA de Protozoário/análise , Infecções Oculares Parasitárias/diagnóstico , Feminino , Humanos , Masculino , Microscopia Confocal , Fosforilcolina/administração & dosagem , Microscopia com Lâmpada de FendaRESUMO
PURPOSE: To report a case series of patients with treatment-resistant Acanthamoeba keratitis (AK) using oral miltefosine, often as salvage therapy. DESIGN: Descriptive, retrospective multicenter case series. METHODS: We reviewed 15 patients with AK unresponsive to therapy who were subsequently given adjuvant systemic miltefosine between 2011 and 2017. The main outcome measures were resolution of infection, final visual acuity, tolerance of miltefosine, and clinical course of disease. RESULTS: All patients were treated with biguanides and/or diamidines or azoles without resolution of disease before starting miltefosine. Eleven of 15 patients retained count fingers or better vision, and all were considered disease free at last follow-up. Eleven of 15 patients had worsening inflammation with miltefosine, with 10 of them improving with steroids. Six patients received multiple courses of miltefosine. Most tolerated oral miltefosine well, with mild gastrointestinal symptoms as the most common systemic side effect. CONCLUSIONS: Oral miltefosine is a generally well-tolerated treatment adjuvant in patients with refractory AK. The clinician should be prepared for a steroid-responsive inflammatory response frequently encountered during the treatment course.
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Ceratite por Acanthamoeba/tratamento farmacológico , Antiprotozoários/administração & dosagem , Fosforilcolina/análogos & derivados , Ceratite por Acanthamoeba/diagnóstico , Administração Oral , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Antiprotozoários/efeitos adversos , Biguanidas/uso terapêutico , Feminino , Humanos , Ceratoplastia Penetrante , Masculino , Pessoa de Meia-Idade , Fosforilcolina/administração & dosagem , Fosforilcolina/efeitos adversos , Estudos Retrospectivos , Terapia de Salvação , Resultado do Tratamento , Acuidade Visual , Adulto JovemRESUMO
In April 2019, the US Food and Drug Administration, in conjunction with 11 professional ophthalmic, vision science, and optometric societies, convened a forum on laser-based imaging. The forum brought together the Food and Drug Administration, clinicians, researchers, industry members, and other stakeholders to stimulate innovation and ensure that patients in the US are the first in the world to have access to high-quality, safe, and effective medical devices. This conference focused on the technology, clinical applications, regulatory issues, and reimbursement issues surrounding innovative ocular imaging modalities. Furthermore, the emerging role of artificial intelligence in ophthalmic imaging was reviewed. This article summarizes the presentations, discussion, and future directions.
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Oftalmopatias/diagnóstico por imagem , Olho/diagnóstico por imagem , Lasers , Oftalmoscópios , Oftalmoscopia , Avaliação da Tecnologia Biomédica , Tomografia de Coerência Óptica/instrumentação , Inteligência Artificial , Difusão de Inovações , Humanos , Interpretação de Imagem Assistida por Computador , Lasers/efeitos adversos , Oftalmoscópios/efeitos adversos , Oftalmoscopia/efeitos adversos , Segurança do Paciente , Valor Preditivo dos Testes , Medição de Risco , Fatores de Risco , Tomografia de Coerência Óptica/efeitos adversos , Estados Unidos , United States Food and Drug AdministrationRESUMO
Fungal infection after corneal transplantation is a rare, yet potentially devastating, postoperative complication and has become a growing concern for the transplant surgeon and eye banking community. The Eye Bank Association of America (EBAA) has reported an increasing trend in the rate of postkeratoplasty fungal infections and a reversal in the previously documented predominance of bacterial over fungal infections. Additionally, several studies have confirmed a high correlation between positive corneoscleral donor rim fungal cultures and postoperative infections. Optisol GS (Bausch & Lomb, Irvine, California, USA), the most extensively used corneal storage solution in US eye banks, does not currently contain any antifungal supplementation. Although large randomised control trials evaluating the efficacy and safety of routine antifungal supplementation to corneal storage solution are lacking, several investigative studies have assessed the role of antifungal agents in reducing fungal contamination of donor corneas without causing undue corneal toxicity. This review will present the current epidemiology of postkeratoplasty fungal infections and evidence for obtaining routine fungal rim cultures and antifungal supplementation of storage solution.
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Antifúngicos/uso terapêutico , Córnea , Doenças da Córnea/prevenção & controle , Transplante de Córnea/efeitos adversos , Infecções Oculares Fúngicas/prevenção & controle , Micoses/prevenção & controle , Soluções para Preservação de Órgãos/uso terapêutico , Doenças da Córnea/etiologia , Criopreservação , Bancos de Olhos , Infecções Oculares Fúngicas/etiologia , Humanos , Micoses/etiologia , Preservação de ÓrgãosRESUMO
PURPOSE: To report the outcomes of medical and surgical management for congenital aniridia-associated keratopathy (AAK) over a long-term follow-up period. DESIGN: Retrospective, comparative case series. METHODS: Medical records of patients diagnosed with congenital aniridia were retrospectively reviewed. Age, sex, ethnicity, follow-up time, AAK stage, noncorneal abnormalities, ocular surgeries, and complications were recorded. The visual acuity equivalent (VAE), approximate Early Treatment Diabetic Retinopathy Study (appETDRS) letter score, was calculated using recorded Snellen visual acuities. RESULTS: A total of 92 eyes of 47 patients (31 females) with mean age of 48.0 ± 18.0 years and mean follow-up of 78.6 ± 42.2 months were included. At the initial visit, 12 eyes (13%) were classified as Stage I AAK, 33 eyes (35.9%) were Stage II, 25 eyes (27.2%) were Stage III, 17 eyes (18.5%) were Stage IV, and 5 eyes (5.4%) were Stage V. Limbal stem cell transplantation (LSCT) and Boston keratoprosthesis (KPro) were frequently performed in eyes with Stages III-V. These advanced corneal surgeries significantly improved the median (95% confidence interval [CI]) of calculated appETDRS scores from 2 (0-20) to 26 (15-41) (Snellen values, 20/20,000 to 20/300; P = 0.0004). Patients with earlier Stages (I-II) of AAK were managed medically and had stable visual acuity through their final visits (appETDRS score of 26 [20-35] to 35 [26-35]; Snellen, 20/300 to 20/200; P > 0.05). The appETDRS VAE was significantly improved from 20 (0-35) to 30 (20-55), Snellen, 20/400 to 20/250, following LSCT (P = 0.021) and from 2 (0-20) to 2 (0-41) after KPro; Snellen, 20/20,000 VAE but with improved 95% CI after follow-up (P = 0.019). CONCLUSIONS: With proper characterization and staging of AAK, individualized medical and advanced surgical interventions preserves and improves visual acuity.
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Aniridia/complicações , Doenças da Córnea/cirurgia , Transplante de Córnea/métodos , Próteses e Implantes , Implantação de Prótese , Adulto , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Transtornos da Visão/cirurgia , Acuidade Visual , Adulto JovemRESUMO
PURPOSE: Descemet stripping endothelial keratoplasty (DSEK), currently the most common procedure for managing corneal endothelial dysfunction, may be repeated following DSEK failure from a variety of causes. This multicenter study reports the risk factors and outcomes of repeat DSEK. METHODS: This was an institutional review board-approved multicenter retrospective chart review of patients who underwent repeat DSEK. Twelve surgeons from 5 Midwest academic centers and 3 private practice groups participated. The Eversight Eye Bank provided clinical indication and donor graft data. We also assessed the role of the learning curve by comparing cohorts from the first and second 5-year periods. RESULTS: A total of 121 eyes from 121 patients who underwent repeat DSEK were identified. The average age of the patients was 70 ± 12 years. The most common indication for repeat DSEK was late endothelial graft failure without rejection (58%, N = 63). Average preoperative and 12-month postoperative repeat DSEK corrected distance visual acuities were 20/694 and 20/89, respectively. Visual acuity outcomes, endothelial cell density, and cell loss did not significantly vary between the 2 cohorts. Initial graft rebubble rates for the first and second cohorts were 51% and 25%. The presence of glaucoma, prior glaucoma surgery, or a history of penetrating (full thickness) keratoplasty did not significantly affect visual outcomes. The median, mean, and range of intraocular pressures before repeat DSEK were 15.0, 15.7, and 6 to 37 mm Hg, respectively. Patients with higher intraocular pressures before repeat DSEK had improved postoperative corrected distance visual acuities. CONCLUSIONS: Repeating DSEK improves vision following failed or decompensated DSEK surgery. Higher preoperative repeat DSEK IOPs were associated with improved visual outcomes, and initial graft rebubble rates, which decreased over time, were likely due to surgeon experience.
Assuntos
Doenças da Córnea/cirurgia , Ceratoplastia Endotelial com Remoção da Lâmina Limitante Posterior/métodos , Idoso , Idoso de 80 Anos ou mais , Doenças da Córnea/fisiopatologia , Perda de Células Endoteliais da Córnea/etiologia , Feminino , Rejeição de Enxerto/patologia , Humanos , Pressão Intraocular/fisiologia , Masculino , Pessoa de Meia-Idade , Reoperação , Estudos Retrospectivos , Fatores de Risco , Acuidade Visual/fisiologiaRESUMO
OBJECTIVE: To identify clinical and demographic factors associated with a worse visual outcome in Acanthamoeba keratitis (AK). DESIGN: Retrospective, case control study. PARTICIPANTS: A total of 72 eyes of 65 patients with AK who were diagnosed at the University of Illinois Eye and Ear Infirmary between May of 2003 and May of 2007 with treatment complete by October of 2007. The first affected eye was analyzed in bilateral disease. METHODS: Patient demographic, clinical characteristics, treatment methods, and final visual outcome data were collected through medical record reviews for all patients diagnosed with AK. Cases were defined as patients with AK with a visual outcome worse than 20/25 or those requiring penetrating keratoplasty (PKP). Controls were defined as patients with AK with a visual outcome of 20/25 or better. Logistic regression was used to estimate the odds ratio (OR) identifying prognostic factors associated with a worse visual outcome. MAIN OUTCOME MEASURES: Final visual outcome worse than 20/25. RESULTS: AK was confirmed through microbiologic evidence in 48 of 65 eyes (73.8%) or with confocal microscopy in 62 of 65 eyes (95.4%). Final visual acuity data were available in 61 of 65 eyes (93.8%); of these 61 eyes, 40 (65.6%) achieved a final visual acuity of 20/25 or better. In multivariable analysis, deep stromal involvement or the presence of a ring infiltrate at presentation was independently associated with worse visual outcomes (OR, 10.27; 95% confidence interval [CI], 2.91-36.17). Symptom duration before diagnosis was statistically predictive of disease stage at presentation (OR, 4.43; 95% CI, 0.99-19.83; multivariable analysis) but not final visual outcome (OR, 2.55; 95% CI, 0.83-7.88; univariate analysis). PKP was performed in 11 of 12 eyes with active disease. CONCLUSIONS: Corneal disease staging at presentation with slit-lamp examination was highly predictive of worse outcomes, allowing the identification of patients who might benefit from more aggressive medical or surgical intervention. Unlike in previous reports, patient-reported duration of symptoms before treatment was not reliable in predicting the final visual result in our series.
Assuntos
Ceratite por Acanthamoeba/diagnóstico , Ceratite por Acanthamoeba/fisiopatologia , Acuidade Visual/fisiologia , Ceratite por Acanthamoeba/terapia , Adulto , Antiprotozoários/uso terapêutico , Benzamidinas/uso terapêutico , Biguanidas/uso terapêutico , Estudos de Casos e Controles , Clorexidina/análogos & derivados , Clorexidina/uso terapêutico , Desbridamento , Desinfetantes/uso terapêutico , Quimioterapia Combinada , Feminino , Humanos , Ceratoplastia Penetrante , Masculino , Prognóstico , Estudos RetrospectivosRESUMO
INTRODUCTION: To present a case of an epithelial inclusion cyst masquerading as an inadvertent bleb in a patient with Marfan syndrome. CASE REPORT: A woman with Marfan syndrome presented with a subluxed crystalline lens in her right eye, which progressively subluxed over the following 2 years. A lensectomy was performed with placement of an anterior chamber intraocular lens (IOL); however, the patient experienced blurred vision and photopsias and preferred IOL explantation. The IOL was removed and a scleral-fixated posterior chamber IOL was placed. Vision improved with an uncomplicated postoperative course. Five months later, the patient experienced sudden onset redness and sharp pain in this eye. A 3-mm cystic lesion with tan material was found over a prior scleral incision site. Intraocular pressure was normal and no aqueous leaked from the lesion. Owing to concerns of an infected inadvertent bleb, treatment with topical and oral antibiotics was started, but the lesion did not change in appearance and the patient experienced persistent pain. The lesion was surgically excised and histopathology revealed a conjunctival epithelial inclusion cyst with intralesional keratin. A month later, another conjunctival inclusion cyst developed and was excised per patient preference. CONCLUSION: Marfan syndrome is characterized by defects in the FBN1 gene and may theoretically lead to an abnormal sclera, increasing the risk of bleb formation after scleral incision. Distinguishing between a filtering bleb and an epithelial inclusion cyst is critical in patient care. Although retained keratin from a cyst may mimic a bleb with purulence, intraocular pressure, aqueous leakage, and response to topical antibiotics may help distinguish between the two.
RESUMO
PURPOSE: To determine the factors that influence the sensitivity and specificity of laser-scanning in vivo confocal microscopy (IVCM) for diagnosing Acanthamoeba keratitis (AK). METHODS: This retrospective, controlled study included 28 eyes of 27 patients with AK and 34 eyes of 34 patients with bacterial keratitis (as the control group). All patients had undergone corneal imaging with a laser-scanning IVCM (Heidelberg Retina Tomograph 3 with the Rostock Cornea Module). The IVCM images were independently evaluated by 2 experienced and 2 inexperienced masked observers. Sensitivity and specificity of IVCM for diagnosing AK and the effects of various clinical and imaging parameters on the sensitivity were then investigated. RESULTS: Overall, IVCM had average sensitivity and specificity of 69.7% ± 2.5% and 97.1% ± 4.2% for experienced observers and 59.0% ± 7.6% and 92.7% ± 10.4% for inexperienced observers, respectively. However, the sensitivity did not show any significant association with the duration of disease, size of ulcer, depth of involvement, culture results, or cyst morphology. Although interobserver agreement was good (κ = 0.60, P < 0.001) for the experienced observers, it was only at a moderate level (κ = 0.48, P < 0.001) for the inexperienced observers. CONCLUSIONS: IVCM has a moderate sensitivity and a high specificity for diagnosis of AK. Although clinical parameters do not affect this diagnostic accuracy, a higher sensitivity is seen when images are interpreted by experienced observers.